HIV-positive patients, whether they are receiving HAART treatment or not, should always be described in the medical record as being “HIV-positive” UNLESS . . .

  • They have ever been diagnosed with AIDS
  • They have ever been diagnosed with an AIDS-defining illness such as:
    • Opportunistic &/or recurrent infections (Candida, Coccidioidomycosis, Cryptococcus, Cryptosporidiosis, Histoplasmosis, Herpes Simplex, Mycobacterium, Pneumocystis, Toxoplasmosis, CMV)
    • Kaposi’s Sarcoma
    • Burkitt’s Lymphoma
  • They have ever been diagnosed as having a CD4 count less than 200

Once a patient has been diagnosed as having any of these things, they should always be described as having AIDS from that point forward and for all future hospitalizations. Please be sure to scour the patient’s past medical record to ensure that they have never been diagnosed with these HIV-related conditions.

If an HIV-positive patient or an AIDS patient presents with any infection, that infection needs to be specified as to whether or not it is due to the HIV/AIDS.

Download the complete tip, HIV.